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PFO / TIA - close the hole?
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PFO / TIA - close the hole?

I am a 42 year old female, runner & cyclist most of my life.  
3 months ago I had a brief "neurological event" where I lost complete control in my left sided limbs. It was preceded by a sharp pain in the left side of my chest, and a feeling of flutter.  I fell into a wall, but did not lose consciousness. This episode lasted around 30 seconds. A radiologist reading the MRI suspected a TIA, but it was subtle in terms of any lesion.  I have been on baby aspirin for several years because of family history of stroke.
For about 9 months I have been having PVCs which doctors consider benign.  I also have frequent strong light headedness (leaving me disoriented at times),  left sided chest pressure, and sometimes burning sensations in my right shoulder blade.  The PVCs have started to worsen over the past couple months, and are now brought on by exercise.
A holter indicated I have frequent bouts of monomorphic PVCs with couplets and brief runs of trigeminy.  An echo found mild mitral and aortic valve regurgitation which the cardiologist thought was an incidental finding.  
My neurologist suspected PFO.  A TCD/bubble test found grade 4 right-to-left shunting during normal respiration; grade 5+ during strain.  A recent TEE verified the PFO, altho I have not been told where the hole is or how large it is.  The nurse showed my husband pics of the images and he said there were hundreds of bubbles passing through during sedated normal respiration (seems very patent).  He said the hole looked to be several millimeters in size.  
Information is conflicted in terms of  whether  a PFO should be closed for prevention of stroke/TIA.  Also, any links to the other symptoms?
So in sum, is it recommended a PFO be closed in situations like mine, or whether I should bump up the amount of aspirin I take and only consider closure if I have another TIA.  I'd hate to have a major stroke, yet don't want to have a surgery that  doesn't buy me much prevention.
Thanks for your time.
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242509_tn?1196926198
Depending on the size of the PFO, it may be able to be closed percutaneously ( with a catheter). Given your symptoms, and presence of right to left shunt with a suspected embolic event, you should undergo closure of the PFO, in order to prevent a CVA or TIA recurrence.
If the percutaneous procedure is not available in your area we have a cardiac specialist in our division which has extensive experience in the percutaneous closure of these PFOs and also ASDs ( which yours is more likely to be given it size). His name is Dr. Rich Krasuski and his office number is (216) 445-7430. If you are interested in his opinion, or the procedure, give his office a call for an appointment.
4 Comments
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Avatar_n_tn
Thank you for your response.  I need to ask the cardiologist performing the TEE (who would also perform the closure if I stay with her) about the size and location of the defect.  She did not talk to me after the TEE, and I don't know if she wants to see me again before the surgery.  She scheduled the closure surgery for the 29th of January (scheduled before she performed the TEE), which I found a little "different".  I may not stay with that date.   I would be worried about a right-to-left shunting ASD, and the potential for pulmonary hypertension.  The TCD indicated a right-to-left atrial septum/pulmonary shunt, but I don't know if that's just the terminology they use.  
I also have weird symptoms of difficulty taking a deep breath at times, and difficulty getting a yawn out.  My lipids are normal, my LVEF is 75%, my BP is around 96/54 and my resting HR is in the 40's.  The only other oddities I feel are my exercise HR sometimes is way higher than what is warranted given my conditioning and the level of exertion when it is high.. meaning it can go well into the 180's and stay there and I am not breathing hard.  Additionally, it will sometimes shoot up drastically in the beginning of exertion after warmup, and then seems to settle down a bit.  I have been told these are nothing to worry about, that everyone is different... so I don't think about it too often.
I live in a major metro area with a top research hospital, yet I may end up calling Dr. Krasuski since I believe Cleveland Clinic is superb in cardiovascular care :)
Thank you very much for your time and this service.
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Avatar_m_tn
Hi,
I am dealing with something similar to you---except I am 59, managing a mild AAA, and out of the blue--my last ECHO, comes up with a possible PFO/ASD and raised pressures in RA---possible Pulmonary Hypertension (IVC failed to collapse). I am also a jogger/runner---over 30 years.  In any event, I live in NYC so there are hospitals here that deal with this.  
I have no symptoms, taking a bubble ECHO next week and possible TEE right after.  I am also having a Chest CAT to check for any pulmonary emboli.  If what i undertand is so, i would be electing to close the PFO or ASD pretty soon in order to reverse or stablisze any further pulmonary hypertension.  Did your ECHO have any evidence of PH or right side heart enlargment? I ask because l am trying to undertand this thing.  Best of luck to you--with today's "medicine" we should be fine!
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Avatar_n_tn
Hi,
I'm not 100% sure what mild AAA is?  I am sorry you are dealing with possible pulmonary hypertension.  That's a tough deal.   I live on the opposite coast of you.. in the San Francisco Bay Area.  We coasties have it made :).  Good luck on the bubble test and  possible TEE.  The TEE is relatively easy... and I hate having things stuck down my throat.  You won't even know it happened.  I was awake at the end of the test (and during I guess) and don't even remember them talking to my hubby!  The original echo didn't say anything about PH, yet I don't believe the doc checked right sided heart "stuff" very thoroughly.  I only see measurements of Left side.  I think he was skeptical of why I was there.  He had talked about doing a tilt table test despite my telling him dizziness wasn't positional.  So, I don't think he knew what to do.  I saw a neuro after who got me going in the right direction.  I do not know the results of my TEE, other than they told my hubby there was a hole that a lot a lot of flow right to left even during sedated respiration.  So, the flap must be very patent because a strain isn't necessary to open it up.  .  That is in line with what the bubble test showed too.  They also said I have a very very small heart  I do wonder about right sided heart pressure, because from what I understand, the flow thru a PFO should only happen during moments when the right sided pressure is higher than left sided pressure.  I know I have cases of left sided chest pressure (thus the right side of my heart) so I wonder what's going on.  I would hope they want to check the pressures between right and left before doing any closure, so I am going to call the cardiologist on Tuesday that performed the TEE.
Best of luck to you on your tests.  Since you are not symptomatic that should be somewhat reassuring to you.  Please post to let me know how things went.  
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Avatar_m_tn
A related discussion, How do you know when a PFO needs to be closed? was started.
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